Saturday, February 7, 2009

DEPRESSIVE DISORDER... notes from a concerned psychiatrist

A merry heart does good, like medicine, but a broken spirit dries the bones
Prov. 17vs22

Everyone have moments of feeling low especially when things go wrong but when this feeling becomes intense and out of control arising from no apparent reason or, even when there is a reason, the intensity and the duration seem out of proportion to the cause, then it could be said to be a depressive disorder. This condition is characterized by a sinking of spirits, lack of courage or initiative, and a tendency to gloomy thoughts.
Depressive disorder is common with a prevalence (will occur at some point in a person’s life) of 5-20% with women twice likely to be affected as men. It ranks fourth as a cause of disability worldwide and has been projected that it may rank second by the year 2020. Race distributions appear equal, and socioeconomic variables do not seem to be a factor. The incidence (rate of new cases) is greatest between the ages of 20 and 40years and it decreases after the age of 65years. It is associated with other physical illnesses, suicide, and drug abuse. It has significant social impact on relationships, families and productivity.

What causes depression is yet to be fully understood, however it is likely to be due to the interplay of multiple variables in the life-span of an individual including biological, psychological, social factors. The biopsychosocial model of depression explains that a genetic factor leads to the individual being vulnerable due to his biological and personality/temperamental make up. Early childhood experiences like separation or loss of parents, traumatic or adverse life experiences, social circumstances, physical abuse or illness could also contribute to one’s vulnerability to depression. All these may then contribute to biological alterations in brain functioning hence the individual becomes increasingly sensitive to the effects of life stressors.
The reason for the gender variation is not also certain but it has been suggested that it may be due to various reasons including hormonal difference (due to increased risk of depression in the premenstrual and post-delivery periods), restricting social and occupational roles (being over- or under-occupied), increased tendency to worry and/or the fact that women are more likely to admit to being depressed whereas men may tend to express themselves differently, for example, through alcohol abuse.

Although depression is very common it often goes undiagnosed and undertreated. Here are some features of depression
Category A:

  • Depressed mood present most of the day, nearly every day, with little variation, and often a lack of responsiveness to changes in circumstances. It may be worse in the morning and improves as the day goes on.

  • Loss of interest and enjoyment

  • Reduced energy and decreased activity
    Category B:

  • Reduced concentration, indecisiveness or diminished ability to think

  • Reduced self-esteem and confidence

  • Ideas of guilt and unworthiness

  • Negative/pessimistic thinking

  • Ideas of self harm, recurrent thought of death or suicide (not ‘fear of dying’) which may or may not be acted upon.

  • Disturbed sleep; either reduced with early morning wakening 2-3hours earlier than usual or increased more than 10hours/day at least 3days a week, for at least 3 months.

  • Weight change associated with either decreased or increased appetite.
    The above symptoms should have been present for at least 2 weeks and represent a change from the individual’s normal behavior. It should also not have been due to the effect of drug/alcohol misuse, medication, a medical disorder, or a loss of a loved one.
    Mild depressive episode: at least 2 of A and at least 2 of B.
    Moderate depressive episode: at least 2 of A and at least 3 of B.
    Severe depressive episode: all 3 of A and at least 4 of B.
    Severity of symptoms and the degree to which these symptoms impair the individuals function also serve as a classification guide.


  • Atypical Depression: it is of moderate severity characterized by overeating, oversleeping, extreme fatigue and heaviness of the limbs, prominent anxiety, and varying gloomy mood but able to enjoy certain experiences though not to normal level. There is also oversensitivity to perceived or real rejection.

  • Seasonal Affective Disorder: there is a clear seasonal pattern to the recurrent depressive episodes, that is, it tends to occur at a particular season of the year. The symptoms are classically depressive symptoms as presented above.
    Postnatal Depression: a significant episode of depression associated with childbirth in 10-15%of women within 6months following delivery. Symptoms are similar to usual depressive disorder. The mother may be bothered about the child’s health or her ability to adequately cope with the baby.
    BIPOLAR DISORDER: though not necessarily a subtype but a mental disorder with two aspects; a manic and a depressive phase. The features of depression are also similar just that these individuals could be tilted to their manic phase by the antidepressant drug (you could read my article on bipolar affective disorder to know more about manic symptoms).
    Depression is responsive to psychotherapy and medications called antidepressants. Milder cases could be treated with brief psychotherapy intervention alone. The more severe cases are treated with combination of medication and psychotherapy this is superior to medication or psychotherapy alone. Among the psychotherapies, cognitive behavioral therapy (which deals with modifying thought patterns) and interpersonal psychotherapy (which deals with resolving personal relationship and life problems) have the most data that support their efficacy however, other psychotherapies like supportive therapy, couple therapy and dynamic therapy are suggested to also be valuable forms of treatment.
    Another important and effective form of treatment which is occasionally used especially in severe or treatment unresponsive cases or when the medication is contraindicated is the Electroconvulsive therapy.
    Untreated cases generally last 6-24months with two thirds achieving spontaneous full recovery.
    Majority of patients have a recurrence of symptoms but individual variation makes it impossible to predict the likely period of recurrence.
    Episodes of recurrent depression tend to be shorter, 4-16weeks.
    Recurrence is greater when there is incomplete recovery (residual symptom of low mood, anxiety, sleep disturbance and so on), previous recurrence, and a strong family history of mood disorder.
    Suicide rates for severe depressive episodes is about 13% (which is 20 times more likely than the general population) with a slightly higher rate of 12-19% for those who have had need for admission.
    There is good evidence that the use of antidepressant medication impacts significantly on all the above data; it reduces the length of depressive episodes, the presence of residual symptoms and the recurrence of symptoms.
    Due to individual differences these factors do not have 100% predictive ability however good predicting factors of the outcome include sudden onset, ‘endogenous’ depression (that is caused by factors within the individual and independent of outside factors) and early age of onset. Poor predicting factors include a slowly creeping in onset of symptoms, low self confidence, alcohol or other drug abuse, personality disorder (for example borderline personality… you can read up my article on BPD), presence of a physical illness and lack of social support.

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